The scientific report guiding the US dietary guidelines: is it scientific?

Response by Nina Teicholz

I’m delighted that The BMJ has stood by this article and decided against retraction. Two outside reviewers judged that the criticisms of the piece did not merit its retraction, and in the end, the corrections made by The BMJ do not, in my view, materially undermine any of the article’s key claims. This article therefore stands as one of the most serious ever, peer-reviewed critiques of the expert report for the US Dietary Guidelines for Americans (DGAs).

The importance of the DGAs, and therefore of this article, should not be understated (and indeed was recognized by many in the mainstream media when the article was published). The DGAs have long been considered the “gold standard,” informing the US food supply, military rations, US government feeding assistance programs such as the National School Lunch Program which are, altogether, consumed by 1 in 4 Americans each month, as well as the guidelines of professional societies and governments around the world, and eating habits generally.

Yet rates of obesity began to shoot upwards in the very year, 1980, that the DGAs were introduced, and the diabetes epidemic began soon thereafter. A critically important yet little understood issue is why the DGAs have failed, so spectacularly, to safeguard health from the very nutrition-related diseases that they were supposed to prevent.

In documenting fundamental failures in the science behind the DGAs, this article offers new insights; It establishes that a vast amount of nutrition science funded by the National Institutes of Health and other governments worldwide has, for decades, been systematically ignored or dismissed, and that therefore, that the DGAs are not based on a comprehensive reviews of the most rigorous science. Incorporating this long-ignored relevant science would likely lead to fundamentally different DGAs and could very well be an important step in infusing them with the power to better fight the nutrition-related diseases.

A fundamental question is why 170+ researchers (including all the 2015 DGA committee members, or “DGAC”), organized by the advocacy group, the Center for Science in the Public Interest (CSPI), would sign a letter asking for retraction. After all, in the weeks following publication, any person had the opportunity to submit a “Rapid Response” to the article, and both CSPI and the DGAC did so, alleging many errors. I responded to them all in my Rapid Response. This is the normal post-publication process.

Yet after all this, CSPI returned for a second round of criticisms, recycling two of the issues (CSPI points #3 and #10) that I had already addressed in my Rapid Response (and which had required no correction), adding another 9 (one of which, #4, contained no challenge of fact), and demanding that based on these alleged errors, the article be retracted. CSPI then circulated this letter widely to colleagues and asked them to sign on.

What is the dangerous information challenging the DGAs that cannot be heard on a conference panel nor published in a peer-reviewed journal?

The major findings of this article are that:
1. The DGAC’s finding that the evidence of a “strong” link between saturated fats and heart disease was not clearly supported by the evidence cited. (Note that as of last year, the Heart and Stroke Foundation of Canada no longer limits saturated fats. Note, also, that Frank Hu, the Harvard epidemiologist in charge of the DGAC review on saturated fats, was an energetic promoter of the retraction letter against my article that critiqued his review, according to emails obtained through FOIA requests);
2. Successive DGA committees have for decades ignored or dismissed a large body of rigorous (randomized controlled trial) literature on the low-fat diet, on more than 50K subjects, collectively finding that this diet is ineffective for fighting obesity, diabetes, heart disease or any kind of cancer;
3. Although the DGAs have for decades recommended avoiding saturated fats and cholesterol to prevent heart disease, no DGA committee has ever directly reviewed the enormous body of rigorous (government-funded, randomized controlled trials) evidence, testing more than 25,000 people, on this hypothesis. Many reviews of this data have concluded that saturated fats have no effect on cardiovascular mortality;
4. The DGAC ignored a large body of scientific literature on low-carbohydrate diets (including several “long term” trials, of 2-years duration) demonstrating that these diets are safe and highly effective for combatting obesity, diabetes, and heart disease;
5. The Nutrition Evidence Library (NEL) set up by USDA to do systematic reviews of the science did not meet its own standards for its review of saturated fats in 2010;
6. Although the DGAC is supposed to consult the NEL to conduct systematic reviews of the science, the 2015 DGAC did so for only 67% of the questions that required systematic reviews;
7. For a number of key reviews, the 2015 DGAC relied on work done in part by the American Heart Association and the American College of Cardiology, which are private associations supported by industry and therefore have a potential conflict of interest;
8. The DGAs, for the first time, introduce the “vegetarian diet” as one of its three, recommended “Dietary Patterns,” yet a NEL review of this diet concluded that the evidence for this its disease-fighting powers is only “limited,” which is the lowest rank of evidence assigned for available data;
9. The DGA’s three recommended “Dietary Patterns” are supported by only limited evidence. The NEL review found only “limited” or “insufficient” evidence that the diets could combat diabetes and only “moderate” evidence that the diets can help people lose weight. The report also gave a strong rating to the evidence that its recommended diets can fight heart disease, yet here, several studies are presented, but none unambiguously supports this claim. In conclusion, the quantity of recommended diets are supported by a small quantity of rigorous evidence that only marginally supports claims that these diets can promote better health than alternatives;
10. The DGA process does not require committee members to disclose conflicts of interest and also that, for the first time, the committee chair came not from a university but from industry;
11. The 2015 DGAC conducted a number of reviews in ways that were not systematic. This allowed for the potential introduction of bias (e.g., cherry picking of the evidence).

This last claim, on the systematic nature of the DGAC reviews, is the subject of the corrections published in The BMJ this week, and refer to CSPI points #1, #2, #7, and #8 (two of which are statements in the text and two of which are in the supporting tables). I am grateful to have had the opportunity to work with The BMJ on developing this notice.

Footnote 1
CSPI has fought for decades to eliminate saturated fats from the American food supply (so much so, that throughout the late 1980s, CSPI advocated for replacing saturated fats with trans fats and succeeded in driving up consumption of trans fats to historic levels, as described in The Big Fat Surprise, pp.227-228). CSPI has also long advocated for shifting away from animal foods containing saturated fats, towards a plant-based diet based on grains and industrial vegetable oils. The researchers who joined CSPI in signing the letter are largely adherents to this view; many have participated in generating the science that has been used to support the hypothesis that fat and cholesterol cause heart disease, and it is upon this hypothesis that the Guidelines have been based.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I am the author of The Big Fat Surprise (Simon & Schuster, 2014), on the history, science, and politics of dietary fat recommendations. I have received modest honorariums for presenting my research findings presented in the book to a variety of groups related to the medical, restaurant, financial, meat, and dairy industries. I am also a board member of a non-profit organization, the Nutrition Coalition, dedicated to ensuring that nutrition policy is based on rigorous science.

The USA based Academy of Nutrition and Dietetics submitted comments supporting the scientific process used by the Dietary Guidelines Advisory Committee in drafting its recommendations for the 2015 Dietary Guidelines for Americans. The Academy’s recommendations to the Departments of Agriculture and Health and Human Services include:1) Supporting the DGAC in its decision to drop dietary cholesterol from the nutrients of concern list and recommending it similarly drop saturated fat from nutrients of concern, given lack of evidence connecting it with cardiovascular disease;

2) Expressing concern over blanket sodium restriction recommendations in light of recent evidence of potential harm to the larger population;

3) Supporting an increased focus on reduction of added sugars as a key public health concern; and

4) Asserting that enhanced nutrition education is critical to any effective implementation.

The final 2015 Dietary Guidelines for Americans are expected to be released at the end of this year.

38 Degrees members deliver a petition of over 410,000 names to the NHS. Their message: Save Our NHS

The Kings Fund, new GMC chairman and Canadian researchers hope so. So do many practising doctors. With the workload pressures, lack of extra resources and retention and recruitment crisis doing nothing is no longer an option. We are very strong on patient education on our site, but no matter how smart we can be about managing our diabetes and associated conditions, there are inevitably times that we will need to see a doctor and go into hospital for some procedure. The better the whole system is running the better it is for patients.

John Toussaint, CEO of the USA ThedaCare Center for Healthcare Value, says that freeing frontline clinicians to solve problems rather than controlling or blaming them could yield major improvements in three years. Organisations should radically change their leadership behaviour, make respect for people a guiding principle and ensure that productivity improvements did not lead to employee lay-offs.”

“Redesigning care to take wasteful steps out of processes improve quality and lower costs at the same time. Leaders must act with humility, take a sincere interest in what their staff are telling them, and build a culture of trust and systems geared to continuous improvement. Senior executives should scrap surplus strategic initiatives that are contributing to staff burn-out, focus on a few core goals, and give proper authority to clinical teams. He said that Western Sussex Hospitals had adopted elements of his system and achieved an outstanding rating from the Quality and Care Commission. He said that the hardest part was eliminating waste in non-clinical areas such as administration, IT, human resources and finance.”

When it comes to eliminating wasteful practice, the Quality and Outcomes framework is a good example. Payment by performance in British General Practice was a massively expensive experiment set up in 2004. In Scotland it has just been abandoned. Almost all GPs hit the desired targets for chronic disease health care identification and monitoring. 25% of GP income was tied to the targets, often of dubious value. Many GPs left or retired and it is believed that the strain of delivering QOF has put many young doctors off being GPs. A study in the Lancet however showed all this was for nothing. There was no benefit to total mortality for any of the diseases covered compared to usual care.

Terrence Stephenson is the current chairman of the General Medical Council in the UK. He delivered a lecture to the Royal Society of Medicine in which he expressed the desire that the GMC shake off the “policeman” image that they have.

“For most doctors, the GMC is known for tackling bad practice and striking doctors off the register. The GMC get 10,000 complaints a year, most of which come from the general public. Making complaints is free, easy and you can even do it online. Unfortunately it can be used in highly inappropriate ways. For instance someone complained that trees from a practice’s garden were blocking their sunlight. Of these complaints 250 are directed to a tribunal and of these 55 doctors were struck off the register.”

“ I think we need reforms to this procedure. Many complaints are erroneous. Many could be dealt with locally. Many patients would be better satisfied if they went through local complaints procedures or the ombudsman. It is my ambition to make the GMC more focussed on patient safety. The sad truth is that medicine is a high risk profession. It is safety critical industry and people are harmed by healthcare. In any human business there will be human error that can never be eradicated but I think it behoves us to try and fix it”.

When it comes to human errors we all know that lack of sleep, overwork, interruptions, boredom, unfamiliarity with the work can all contribute. Being hungry and thirsty also impair us.

Canadian researchers suggest regular meal breaks for doctors. Many work long shifts with no guaranteed breaks. Healthy food should be available. (Not just sandwiches and crisps I hope!). Food outlets should be open 24 hours to accommodate shift workers. Staff should be able to store and eat food near to where they actually work. They also suggest that professional bodies increase awareness of doctors’ nutrition and their well-being and promote self-care for doctors.

Based on several articles in the BMJ 4 June 16

Ending blame culture would improve NHS care in three years by Matthew Limb freelance journalist

I’ve never harboured political ambitions. I’ve no idea how you would go about devising the best practices and policies for running the country. And Ms May’s biggest job at the moment is negotiating the exit from the EU.

But her appointment did get me thinking. How on earth do you cope with diabetes and the heavy responsibility of country leadership? Fair enough, she’s had a senior political role for some time so the transition probably isn’t that much of a leap, but even so… How do you do it?

What happens if you have a hypo in the middle of Prime Minister’s Question Time? My brain starts to go slightly mushy and I get easily confused when I’m hypo. Mushy brains don’t lend themselves to debate.

How do you cope with the interruption of routine? My diabetes is best controlled when routines stay constant – the same time for meals, the same levels of activity, the same sorts of foods and the same time to bed. Life at any kind of senior level doesn’t lend itself to regular routines.

How do you fit in hospital appointments? At the very least, she should be attending clinics every six months and also having regular retinal screening appointments. If you’re a very senior politician, I imagine hospital appointments often have to be cancelled at very short notice.

Blood pressure. As a diabetic, you are more likely to suffer high blood pressure than most people. Is being prime minister at all good for your blood pressure?

How do you manage with all the eating out? Good blood sugar management means you need to know the carbohydrate values of what you are eating, which is tricky when you are eating out.

Anyway, I don’t agree with her politics, but I don’t – and wouldn’t question – her ability to do the job. It’s interesting to reflect on the impact of a chronic condition on someone working at that kind of level. Diabetes often requires huge efforts of will power – overcoming the tiredness, forcing yourself to be organised enough to remember all your equipment and carry spare food and sweets just in case etc. Sometimes, all you want to do is sleep, the prospect of even a conversation too exhausting to cope with.

When you’re working at Theresa May’s level, you must need vast quantities of that will power and determination. Ms May, I salute you.

The vote to take the UK out of the EU has chilled me to the bone. Social well-being is inextricably linked to health and a careless decision taken by a majority of around 52% of voters has just messed up our economic system on which our well-being as citizens and patients depends.

Scotland, Northern Ireland, central London and Gibraltar have unequivocally voted to stay in the EU. There are 1.3 million Brits who study, work or have retired to the EU, and many of these people were not able to vote in the referendum. If they had, the margin of success for Brexit would have been lessened considerably.

The people who voted to stay tended to be younger, have degrees, have jobs, and be wealthier. Those who wanted to leave tended to be older, be on benefits and perhaps feel that they will be more sheltered from the effects of their choice.

Economists, business leaders, bankers, most MPs, and the British Medical Association which represents the majority of UK doctors, all want to stay in the EU. Reasoned discussion has been going on for months in such papers as the Guardian and the Times. Pictures of the Union Jack, the Queen, and rants about immigration and the millions that could be diverted to the NHS have been on the front pages of the tabloids for months. On the very morning of the result, Mr Farage, leader of the UKIP party, admitted that the slogans on the buses and billboards about money going to the NHS from the EU were lies. “Nothing to do with me”, he said.

Meanwhile the UK has lost David Cameron as Prime Minister. He has been an emotionally stable, sensible, well informed, inclusive, solution seeking head of the government. Very far from Maggie Thatcher or Tony Blair in performance or nature, he has felt the need to step down, despite demonstrating an integrity that Farage and the likes do not appear to emulate.

So, what has the EU done for us? Quite a lot as far as I can see. Most of it beneficial.

We have a decimal currency, much easier than the old 12 unit system. We get cheap good quality food, particularly fruit, vegetables, wine, ham, olive oil, nuts and cheese. Many of these items feature heavily in a low carbohydrate Mediteranean style diet which is so important in keeping well if you have diabetes.

For doctors, the European Working Time Directive, which limits junior hospital doctors working hours to 48 hours a week was a God send. I used to work 120-145 hours a week as a junior doctor. It was described as “training” but it was slave labour. I was paid one third of my basic rate for the extra hundred or so hours I was on evenings and weekends. On Christmas day 1983 I earned 50 pence per hour and that was before tax. Older doctors and consultants didn’t care. They did nothing about it. If we did it and survived, you can too was the mentality. It took the EU to get doctors out of that mess and without the working directive it could easily revert back.

There is a workforce crisis in UK medicine as it is. Worsening of terms and conditions for doctors will lead even more of them to jack it in and head for Australia.

What of our working population generally? The EU have brought in laws to give reasonable hours, breaks, holidays and contracts to workers. Without the EU there will be more likelihood for zero hour contracts to become the norm, if you can even get a job.

When it comes to selling a house, the main thing that estate agents say are important are location, location, location. When it comes to the well -being of a countries citizens the important things are economy, economy, economy.

Like it or lump it, we are all part of a global economy now. The EU is not responsible for all the bad things that are happening that affect the economy. The immigration crisis is due to an undeclared third world war which is due to Islamic separatists destroying these people’s homes, countries and own economies.

A government can’t hand out money to sick people, the unemployed, the NHS or anyone else unless they have money raised from taxation. They can’t get this unless people have jobs. If the economists are right, and there is no reason to believe that they will not be, there will be fewer jobs, worse terms and conditions, less money able to be raised from tax and therefore less money for pensions, benefits and health care.

Leaving the EU is not a vote for prosperity.

What can we do about it?

To really improve things we need to get a review of the referendum decision. If it can’t happen for the whole of the UK, the best option in my view, then perhaps it can be achieved in Scotland. This would mean a difficult choice for Scots. Do we stay with England and Wales? Do we stay with Europe?

When people look across at Southern Ireland it would appear that they have not done very well in terms of economic prosperity by staying in the EU. On the other hand do we revert back to the dark ages with the working classes being over worked and underpaid with a deficient social care system but with an elite few at the top as could happen for England and Wales?

What do you think of the result of the vote? What do you think we can do to makes things less awful than what has been predicted for us all?

The UK government has released a new version of the risable “Eat well plate” which gives us at diabetesdietblog.com even more heartburn, if that were possible.

In this they have given due pominence to fruit and vegetables but have also advised even more starch such as bread, potatoes, breakfast cereals, pasta and rice. Low fat dairy is encouraged and protein is under represented again. Vegetable oil and low fat spread is given a little sliver of prominence. They have advised us to eat 30g of fibre a day and limit sugar to 30g a day. Lordy, some of us don’t even eat this in total carbs a day! They have said that 150g of fruit juice or smoothie can count as one of “your five a day”.

The government are grimly determined to back a diet that will lead to more obesity, diabetes, acid reflux, cancer and cardiovascular disease. Isn’t the NHS in enough of a mess already? Obviously the government don’t think so.